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Healthcare Form Templates

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BMI & Body Composition Form
Patient Name
Date of Measurement
Weight (lbs/kg)
Height (in/cm)
BMI recording
BMI Classification
Waist Circumference
Body Fat Percentage
Submit
Screening

BMI & Body Composition Form

Customize the BMI & Body Composition template for your practice. 10 editable fields, including Patient Name, Date of Measurement, Weight (lbs/kg), Height (in/cm).

1 page•10 fields
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Patient Name
Date of Birth
Date of Screening
Have you felt you should Cut down on drinking?
Have people Annoyed you by criticizing your drinking?
Have you felt Guilty about your drinking?
Have you had a morning Eye-opener drink?
Current Drinking Frequency
Submit
Screening

CAGE Alcohol Screening Questionnaire

Customize the CAGE Alcohol Screening Questionnaire template for your practice. 12 editable fields, including Patient Name, Date of Birth, Date of Screening, Have you felt you should Cut down on drinking?.

2 pages•12 fields
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Employee Full Name
Date of Birth
Email Address
Employer & Department
Biometric Measurements
Blood Pressure & Heart Rate
Lifestyle & Health Habits Assessment
Tobacco, Alcohol & Substance Use
Submit
Screening

Corporate Wellness Screening Form

Customize the Corporate Wellness Screening template for your practice. 12 editable fields, including Employee Full Name, Date of Birth, Email Address, Employer & Department.

2 pages•12 fields
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Patient Name
Date of Birth
Age
Alcohol Use in Past 12 Months
Cannabis Use in Past 12 Months
Other Substance Use in Past 12 Months
Ridden in a Car with impaired driver?
Used substances to Relax?
Submit
Screening

CRAFFT Adolescent Substance Abuse Screening

Customize the CRAFFT Adolescent Substance Abuse Screening template for your practice. 14 editable fields, including Patient Name, Date of Birth, Age, Alcohol Use in Past 12 Months.

2 pages•14 fields
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Patient Name
Date of Screening
Used drugs other than for medical reasons?
Abused prescription drugs?
Able to stop using drugs when you want?
Blackouts or flashbacks from drug use?
Feel guilty about drug use?
Spouse or parents complain about drug use?
Submit
Screening

DAST-10 Drug Abuse Screening

Customize the DAST-10 Drug Abuse Screening template for your practice. 12 editable fields, including Patient Name, Date of Screening, Used drugs other than for medical reasons?, Abused prescription drugs?.

2 pages•12 fields
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Patient Name
Date of Screening
Used drugs other than for medical reasons?
Abused prescription drugs?
Able to stop using drugs when you want?
Blackouts or flashbacks from drug use?
Feel guilty about drug use?
Spouse or family complains about drug use?
Submit
Screening

DAST-10 Drug Abuse Screening Test

Customize the DAST-10 Drug Abuse Screening Test template for your practice. 14 editable fields, including Patient Name, Date of Screening, Used drugs other than for medical reasons?, Abused prescription drugs?.

2 pages•14 fields
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Patient Name
Date of Birth
Current Weight & Height
Weight History
Dieting & Food Preoccupation
Binge Eating Behavior
Purging & Compensatory Behaviors
Exercise Patterns
Submit
Screening

Eating Disorder Screening Form

Customize the Eating Disorder Screening template for your practice. 13 editable fields, including Patient Name, Date of Birth, Current Weight & Height, Weight History.

2 pages•13 fields
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Patient Name
Date of Screening
Baby's Date of Birth
Able to Laugh and See Funny Side
Looked Forward to Things with Enjoyment
Blamed Self Unnecessarily
Anxious or Worried for No Good Reason
Felt Scared or Panicky
Submit
Screening

Edinburgh Postnatal Depression Scale Form

Customize the Edinburgh Postnatal Depression Scale template for your practice. 12 editable fields, including Patient Name, Date of Screening, Baby's Date of Birth, Able to Laugh and See Funny Side.

2 pages•12 fields
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Epworth Sleepiness Scale
Patient Name
Date of Birth
Sitting and Reading
Watching Television
Sitting Inactive in a Public Place
As a Passenger in a Car for an Hour
Lying Down to Rest in Afternoon
Sitting and Talking to Someone
Submit
Screening

Epworth Sleepiness Scale

Customize the Epworth Sleepiness Scale template for your practice. 12 editable fields, including Patient Name, Date of Birth, Sitting and Reading, Watching Television.

2 pages•12 fields
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Fall Risk Screening Form
Full Name
Fall History (Past 12 Months)
Fall Circumstances & Injuries
Current Medications (Count)
High-Risk Medications
+
Add
Balance & Mobility Confidence
Vision Concerns
Home Environmental Hazards
Submit
Screening

Fall Risk Screening Form

Customize the Fall Risk Screening template for your practice. 10 editable fields, including Full Name, Fall History (Past 12 Months), Fall Circumstances & Injuries, Current Medications (Count).

1 page•10 fields
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Patient Name
Date of Evaluation
Referring Provider
Job Title / Occupation
Lifting Capacity (Floor to Waist)
Carrying Tolerance
Standing Tolerance (minutes)
Walking Tolerance (minutes)
Submit
Screening

Functional Capacity Evaluation Form

Customize the Functional Capacity Evaluation template for your practice. 16 editable fields, including Patient Name, Date of Evaluation, Referring Provider, Job Title / Occupation.

2 pages•16 fields
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GAD-7 Anxiety Screening
Patient Name
Date of Birth
Date
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
Submit
Screening

GAD-7 Anxiety Screening

Customize the GAD-7 Anxiety Screening template for your practice. 11 editable fields, including Patient Name, Date of Birth, Date, 1. Feeling nervous, anxious, or on edge.

1 page•11 fields
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Patient Name
Date of Birth
Date of Screening
Satisfied with Life
Dropped Activities and Interests
Feel Life is Empty
Often Get Bored
In Good Spirits Most of the Time
Submit
Screening

Geriatric Depression Scale (GDS) Form

Customize the Geriatric Depression Scale (GDS) template for your practice. 15 editable fields, including Patient Name, Date of Birth, Date of Screening, Satisfied with Life.

2 pages•15 fields
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Patient Name
Date of Screening
Repeated disturbing memories
Repeated disturbing dreams
Suddenly feeling as if the event were happening again
Feeling upset when reminded of the event
Physical reactions when reminded
Avoiding memories or thoughts
Submit
Screening

PCL-5 PTSD Screening Checklist

Customize the PCL-5 PTSD Screening Checklist template for your practice. 22 editable fields, including Patient Name, Date of Screening, Repeated disturbing memories, Repeated disturbing dreams.

3 pages•22 fields
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Child's Name
Date of Birth
Child's Age (months)
Parent/Guardian Name
Gestational Age at Birth
Communication Milestones
Gross Motor Skills
Fine Motor Skills
Submit
Screening

Pediatric Developmental Screening Form

Customize the Pediatric Developmental Screening template for your practice. 14 editable fields, including Child's Name, Date of Birth, Child's Age (months), Parent/Guardian Name.

2 pages•14 fields
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Patient Name
Date of Birth
Date
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
Submit
Screening

PHQ-9 Depression Screening

Customize the PHQ-9 Depression Screening template for your practice. 13 editable fields, including Patient Name, Date of Birth, Date, 1. Little interest or pleasure in doing things.

1 page•13 fields
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Patient Name
Date of Screening
Brief Trauma Description
Repeated, disturbing memories
Repeated, disturbing dreams
Suddenly feeling as if the event were happening again
Avoiding memories, thoughts, or feelings
Avoiding external reminders
Submit
Screening

PTSD Checklist (PCL-5) Screening

Customize the PTSD Checklist (PCL-5) Screening template for your practice. 14 editable fields, including Patient Name, Date of Screening, Brief Trauma Description, Repeated, disturbing memories.

2 pages•14 fields
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Social Determinants of Health Screening
Full Name
Food Security
Housing Stability
Utility Difficulties
Transportation Access
Financial Strain
Personal Safety
Social Isolation
Submit
Screening

Social Determinants of Health Screening

Customize the Social Determinants of Health Screening template for your practice. 11 editable fields, including Full Name, Food Security, Housing Stability, Utility Difficulties.

2 pages•11 fields
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Patient Name
Date of Birth
Do you Snore loudly?
Do you often feel Tired during the day?
Has anyone Observed you stop breathing during sleep?
Are you treated for high Blood Pressure?
BMI greater than 35?
Age over 50 years?
Submit
Screening

STOP-BANG Sleep Apnea Screening

Customize the STOP-BANG Sleep Apnea Screening template for your practice. 12 editable fields, including Patient Name, Date of Birth, Do you Snore loudly?, Do you often feel Tired during the day?.

2 pages•12 fields
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Full Name
Have you felt you should cut down?
Have people annoyed you about your use?
Have you felt guilty about your use?
Have you used first thing in the morning?
Alcohol Use Frequency
Drug Use Frequency
Tobacco/Nicotine Use
Submit
Screening

Substance Use Screening (CAGE-AID)

Customize the Substance Use Screening (CAGE-AID) template for your practice. 11 editable fields, including Full Name, Have you felt you should cut down?, Have people annoyed you about your use?, Have you felt guilty about your use?.

2 pages•11 fields
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Child's Name
Date of Birth
Child's Age
Grade Level
Parent/Guardian Name
Difficulty sustaining attention
Does not seem to listen
Easily distracted
Submit
Screening

Vanderbilt ADHD Assessment Screening

Customize the Vanderbilt ADHD Assessment Screening template for your practice. 14 editable fields, including Child's Name, Date of Birth, Child's Age, Grade Level.

2 pages•14 fields
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Advance Directive Form
Full Name
Date of Birth
Life-Sustaining Treatment Preferences
Cardiopulmonary Resuscitation (CPR) Preference
Mechanical Ventilation Preference
Artificial Nutrition and Hydration Preference
Healthcare Proxy Name
Healthcare Proxy Phone Number
Submit
Registration

Advance Directive Form

Customize the Advance Directive template for your practice. 14 editable fields, including Full Name, Date of Birth, Life-Sustaining Treatment Preferences, Cardiopulmonary Resuscitation (CPR) Preference.

1 page•14 fields
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Appointment Request Form
Full Name
Date of Birth
Email
Phone Number
Preferred Doctor (if applicable)
Reason for Appointment
Preferred Date and Time
Alternative Dates/Times
Submit
Registration

Appointment Request Form

Customize the Appointment Request template for your practice. 11 editable fields, including Full Name, Date of Birth, Email, Phone Number.

1 page•11 fields
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Clinical Trial Enrollment Form
Full Legal Name
Date of Birth
Phone Number
Email Address
Home Address
Study Name / Protocol Number
Primary Care Physician
Current Medications
+
Add
Submit
Registration

Clinical Trial Enrollment Form

Customize the Clinical Trial Enrollment template for your practice. 15 editable fields, including Full Legal Name, Date of Birth, Phone Number, Email Address.

2 pages•15 fields
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Emergency Contact Form
Patient Full Name
Date of Birth
Primary Emergency Contact Name
Relationship to Patient
Select...
Primary Contact Phone
Primary Contact Email
Secondary Emergency Contact Name
Secondary Contact Phone
Submit
Registration

Emergency Contact Form

Customize the Emergency Contact template for your practice. 11 editable fields, including Patient Full Name, Date of Birth, Primary Emergency Contact Name, Relationship to Patient.

2 pages•11 fields
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Full Name
Date of Birth
Phone Number
Email Address
Preferred Session Date
Health Topics of Interest
Group Format Preference
Accommodation Needs
Submit
Registration

Group Visit Registration Form

Customize the Group Visit Registration template for your practice. 10 editable fields, including Full Name, Date of Birth, Phone Number, Email Address.

1 page•10 fields
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Infusion Therapy Registration Form
Patient Name
Date of Birth
Primary Diagnosis
Prescribed Infusion
Prescribing Physician
Insurance Information
Prior Authorization Number
Known Allergies
Submit
Registration

Infusion Therapy Registration Form

Customize the Infusion Therapy Registration template for your practice. 10 editable fields, including Patient Name, Date of Birth, Primary Diagnosis, Prescribed Infusion.

1 page•10 fields
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Patient Name
Date of Birth
Records to Release
Release To (Name of Person or Organization)
Release To (Address)
Purpose of Release
Expiration Date of Authorization
I understand that I have the right to revoke this authorization at any time by providing written notice to the practice, and that revocation will not apply to information already released.
Submit
Registration

Medical Records Release Form

Customize the Medical Records Release template for your practice. 11 editable fields, including Patient Name, Date of Birth, Records to Release, Release To (Name of Person or Organization).

1 page•11 fields
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Patient Full Name
Date of Birth
Phone Number
Email Address
Current Diagnosis
Current Treating Physician
Proposed Treatment Plan
Specific Questions & Concerns
Submit
Registration

Medical Second Opinion Request Form

Customize the Medical Second Opinion Request template for your practice. 14 editable fields, including Patient Full Name, Date of Birth, Phone Number, Email Address.

2 pages•14 fields
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Medication Refill Request Form
Full Name
Date of Birth
Medication Name
Dosage
Pharmacy Name
Pharmacy Phone Number
Additional Comments
Signature
Sign here
Submit
Registration

Medication Refill Request Form

Customize the Medication Refill Request template for your practice. 8 editable fields, including Full Name, Date of Birth, Medication Name, Dosage.

1 page•8 fields
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